Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place
TLDR
It is suggested that incident reporting does not provide an adequate assessment of clinical adverse events and that this method needs to be supplemented with other more systematic forms of data collection.Abstract:
Background: Over the past five years, in most hospitals in England and Wales, incident reporting has become well established but it remains unclear how well reports match clinical adverse events. International epidemiological studies of adverse events are based on retrospective, multi-hospital case record review. In this paper the authors describe the use of incident reporting, pharmacist surveillance and local real-time record review for the recognition of clinical risks associated with hospital inpatient care.
Methodology: Data on adverse events were collected prospectively on 288 patients discharged from adult acute medical and surgical units in an NHS district general hospital using incident reports, active surveillance of prescription charts by pharmacists and record review at time of discharge.
Results: Record review detected 26 adverse events (AEs) and 40 potential adverse events (PAEs) occurring during the index admission. In contrast, in the same patient group, incident reporting detected 11 PAEs and no AEs. Pharmacy surveillance found 10 medication errors all of which were PAEs. There was little overlap in the nature of events detected by the three methods.
Conclusion: The findings suggest that incident reporting does not provide an adequate assessment of clinical adverse events and that this method needs to be supplemented with other more systematic forms of data collection. Structured record review, carried out by clinicians, provides an important component of an integrated approach to identifying risk in the context of developing a safety and quality improvement programme.read more
Citations
More filters
Journal ArticleDOI
Medication Monitoring for People with Dementia in Care Homes: The Feasibility and Clinical Impact of Nurse-Led Monitoring
Sue Jordan,Marie E. Gabe,Louise Newson,Sherrill Snelgrove,Gerwyn Panes,Aldo Picek,Ian Russell,Michael Dennis +7 more
TL;DR: Clinical trials of the West Wales Adverse Drug Reaction (ADR) Profile for Mental Health Medicines are feasible and necessary and participants benefited from structured nurse-led medication monitoring.
Making health care safer II: an updated critical analysis of the evidence for patient safety practices.
Paul G. Shekelle,Robert M. Wachter,Peter J. Pronovost,Karen M Schoelles,Kathryn M. McDonald,Sydney M. Dy,Kaveh G. Shojania,James Reston,Zackary Berger,Breanne Johnsen,Jody Larkin,Scott Lucas,Kathryn A. Martinez,Aneesa Motala,Sydne J Newberry,Meredith Noble,Elizabeth R. Pfoh,Sumant R. Ranji,Stephanie Rennke,Eric W. Schmidt,Roberta M. Shanman,Nancy Sullivan,Fang Sun,Kelley Tipton,Jonathan Treadwell,A Tsou,Mary E. Vaiana,Sallie J. Weaver,Renee F Wilson,Bradford D. Winters +29 more
TL;DR: The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade, and evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness.
Journal ArticleDOI
Clinical and economic burden of adverse drug reactions.
TL;DR: Overall, pharmacovigilance is aimed at identifying drug safety signals as early as possible, thus minimizing potential clinical and economic consequences of ADRs, and reducing healthcare costs in the process.
Journal ArticleDOI
Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review.
TL;DR: Overall, it is clear that prescribing errors are a common occurrence, affecting 7% of medication orders, 2% of patient days and 50% of hospital admissions, however, the reported rates of prescribing errors varied greatly and this could be partly explained by variations in the definition of a prescribing error, the methods used to collect error data and the setting of the study.
An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education
TL;DR: Overall it is clear that prescribing errors are a common occurrence affecting 7% of orders, 2% of patient days and 50% of hospital admissions, however, the reported rates of prescribing errors varied greatly and this could be partly because of the number of studies conducted.
References
More filters
Journal ArticleDOI
Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.
Troyen A. Brennan,Lucian L. Leape,Nan M. Laird,Liesi E. Hebert,A R Localio,Ann G. Lawthers,Joseph P. Newhouse,Paul C. Weiler,Howard H. Hiatt +8 more
TL;DR: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.
Journal ArticleDOI
The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada
G. Ross Baker,Peter G. Norton,Virginia Flintoft,Régis Blais,Adalsteinn D. Brown,Jafna L. Cox,Edward Etchells,William A. Ghali,Philip C. Hébert,Sumit R. Majumdar,Maeve O'Beirne,Luz Palacios-Derflingher,Robert J. Reid,Sam Sheps,Robyn Tamblyn +14 more
TL;DR: The overall incidence rate of AEs of 7.5% in this study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.
Journal ArticleDOI
The Quality in Australian Health Care Study
Ross McL Wilson,William B. Runciman,Robert W. Gibberd,Bernadette T Harrison,Liza Newby,John D. Hamilton +5 more
TL;DR: A review of the medical records of over 14 000 admissions to 28 hospitals in New South Wales and South Australia revealed that 16.6% of these admissions were associated with an “adverse event”, which resulted in disability or a longer hospital stay for the patient and was caused by health care management.
Journal ArticleDOI
Error in Medicine
TL;DR: Evidence from a number of sources indicates that a substantial number of patients suffer treatment-caused injuries while in the hospital, and inappropriate use of drugs was the leading cause of injuries.
Journal ArticleDOI
Adverse events in british hospitals: preliminary retrospective record review
TL;DR: These results suggest that adverse events are a serious source of harm to patients and a large drain on NHS resources.